Provider Demographics
NPI: | 1972863298 |
---|---|
Name: | INTERACTIVE MED-UNLIM SURG ASSIST |
Entity type: | Organization |
Organization Name: | INTERACTIVE MED-UNLIM SURG ASSIST |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MIGUEL |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | ORTIZ-DIAZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PAC |
Authorized Official - Phone: | 954-990-3515 |
Mailing Address - Street 1: | 49 N FEDERAL HWY |
Mailing Address - Street 2: | SUITE 361 |
Mailing Address - City: | POMPANO BEACH |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33062-4304 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 954-990-3515 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 49 N FEDERAL HWY |
Practice Address - Street 2: | SUITE 361 |
Practice Address - City: | POMPANO BEACH |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33062-4304 |
Practice Address - Country: | US |
Practice Address - Phone: | 954-990-3515 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-05-21 |
Last Update Date: | 2012-05-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |